International Symposium on International Symposium on Household Water ManagementHousehold Water Management

Bangkok, ThailandBangkok, ThailandJune 1June 1--2, 20052, 2005

Perceived Attributes of Water and Their

EffectsOn Water Treatment

in Guatemala

and Pakistan

D. Lawrence Kincaid & Maria Elena Figueroa

Personal Hygiene

Personal Sanitation

Community Sanitation

Domestic Hygiene

Safe Drinking

Water

Behavior Cluster

Travel Drinking Water

Children’s Neighborhood Drinking Water

Clothes Washing

WaterBathing Water

Water for Food Preparation

Hand Washing

Boiled Water

Bottled Water

Gas Stove

Fuel Supply &

Cost

Soap Supply &

Cost

Chlorine Supply &

Cost

Toilets or Latrines

Diarrhea

Skin Diseases

Malnutrition

Upper Respiratory

Infection

Water Treatment as a Cluster of Related Behaviors & Diseases

Tap Water Quality

Sewers & Latrines

Trash Removal

Processed Water: Tea Coffee, SodaORT and

Antibiotics Availability

& Cost

Model of Communication and Hygiene Behavior

COMMUNICATION

PSYCHO-SOCIAL FACTORS

COGNITIVEBeliefsValuesPerceived RiskSubjective NormsSelf-Image

EMOTIONALEmotional ResponseEmpathySelf-Efficacy

SOCIAL Bounded Norm. InfluencePersonal Advocacy

ENVIRONMENTAccess to Water Sources & Tech-nology, Community Sanitation &Community Organizations

SKILLS & KNOWLEDGEINSTRUCTION

NONDIRECTIVEDialogueCounselingEntertainmentSocial Networks

PUBLICServices Advocacy

reinforcement

enabling

Attitudes INTENTION

BEHAVIORSafe Drinking Water

Household Sanitation

Hand Washing

Community Action

DIRECTIVEDisseminationPromotionPrescription

confirmation

A predictive model of communication & change:Influence of ideational elements on behavior

Implies simultaneous effect of all influences.

KnowledgePersonal Advocacy Attitudes

Self-Image

Perceived Risk

Self-Efficacy Norms

Emotions

BEHAVIOR

Social Support & Influence

Implies communication can affect all influences.

Water treatment behavior Guatemala, 2003Water treatment behavior Guatemala, 2003

Treatment Method

35.5

2.5 1.2 0.3 0.5

60.1

0

20

40

60

80

100

Nottreating

Boiling Chlorine Filter PUR Other*

Percentage

Sample size = 1,500* Includes filter w/cloth/strainer, solar disinfection and others.

Adjusted odds ratios of 6 psychosocial factors Adjusted odds ratios of 6 psychosocial factors related to water treatment related to water treatment Guatemala, 2003Guatemala, 2003

Psychosocial Factors

1.91.4 1.2

1.7 1.3

5.2

0

1

2

3

4

5

6

TreatmentAttitude

Taste ofBoiledWater

Odds Ratio

Boiled Water asNatural

SocialNorm

Self-Confi-dence

DiscussWithPartner

National survey by MERTUN= 1,446; R2 = 0.19 70.6% correctly classified

Controls include: Source of water, drinks bottled water, knowledge water-illness, socio-demographic factors, SES, plus other control variables.

Percent of water treatment by the number of Percent of water treatment by the number of ideational factors which applyideational factors which apply

Guatemala 2003Guatemala 2003

Cumulative Number of Factors that Apply

17

3441

6369

40

7

0

20

40

60

80

100

None 1 2 3 4 5 Overall

Percent

Chi2 (5 df) = 176.8 p<.001; N = 1,500

Table 1. Regression of water treatment on psychosocial, communication, & socio-demographic control variables among Guatemalan women, 2003 ______________________________________________________________________________ Logistic regression Number of obs = 1446 LR chi2(25) = 362.45 Log likelihood = -794.56395 Prob > chi2 = 0.0000 Pseudo R2 = 0.1857 Water | Treatment | Odds Ratio Std. Err. z P>|z| [95% Conf. Interval] COGNITIVE-EMO| Attitudes | 5.231126 1.289652 6.71 0.000 3.226598 8.48097 Self-Confid. | 1.871891 .3454678 3.40 0.001 1.303727 2.687661 Taste/Boiled | 1.741877 .1619398 5.97 0.000 1.451719 2.09003 NaturalBoiled| 1.272286 .1179611 2.60 0.009 1.060876 1.525824 Water-Disease| 1.103860 .0664646 1.64 0.101 .9809843 1.242126 SOCIAL INFL | Talk Partner | 1.435664 .1828814 2.84 0.005 1.118466 1.842819 Social Norm | 1.248708 .0618986 4.48 0.000 1.133096 1.376116 Church Attend| 1.066298 .0323361 2.12 0.034 1.004767 1.131597 Mass Media | 2.668498 .7173874 3.65 0.000 1.575555 4.519602 HYGIENE BEHAV| Hand Washing | 1.295699 .1853092 1.81 0.070 .9789629 1.714912 Bottle Water | 0.124493 .0314385 -8.25 0.000 .0758909 .2042211 River Water | 2.193061 .8400946 2.05 0.040 1.035098 4.646437 SOCIO-DEMOGR | SES | 1.021658 .0112415 1.95 0.051 .9998608 1.04393 Age | 1.001926 .0062439 0.31 0.758 .9897621 1.014238 Education | 1.116608 .1275622 0.97 0.334 .8926041 1.396827 N of Children| 0.978454 .0250698 -0.85 0.395 .9305315 1.028845 Urban | 1.044929 .1599188 0.29 0.774 .7741345 1.410447 Spanish Lang.| 0.854877 .139466 -0.96 0.336 .620923 1.176983 TV in Home | 0.764067 .118577 -1.73 0.083 .5636795 1.035693 Radio in Home| 0.958506 .2224302 -0.18 0.855 .6082274 1.510512 NE Region | 2.662775 .7091981 3.68 0.000 1.579892 4.487886 SW Region | 1.563983 .3157664 2.22 0.027 1.052871 2.323211 NW Region | 1.719143 .3850765 2.42 0.016 1.108278 2.666708 SE Region | 1.467461 .4857023 1.16 0.247 .7670698 2.807363 * Centeral region is the reference category for regions. 70% Correctly classified; Hosmer-Lemeshow Chi2(13)=16.97 Prob > chi2 = 0.2005

Conceptual Model of Water Treatment Behavior in Guatemala

Exogenous Factors

Socio-DemographicCharacteristics

Education LevelLanguageAgeGenderMarital StatusNo. of ChildrenSocio-Econ. StatusChurch AttendanceTV/Radio OwnershipHand Washing HabitHealth Promoter

Psycho-social Factors

CognitiveKnows water causes

diarrheaEmotional

Worried about children’s diarrhea

Taste of Boiled Water (rich and natural)

ConfidenceSocial Influence

Perceived NormDiscussion with

partner and friends

Behavioral Outcome

TreatmentAttitude

Environmental Constraints:

Water Source--River & Bottled

Rural ResidenceRegion

Water Treatment

Exposure to Mass Media Promotional

Messages

Interventions

70.6% correctly classified

Summary of results from GuatemalaSummary of results from GuatemalaAll else being equal, people in Guatemala who treat their water regularly are those who:• have positive attitudes toward water treatment• like the taste of boiled water and perceive it

as natural• have self-confidence in the water they prepare• have talked to their partner about treating water• believe that the majority treats their water• wash their hands at critical times• have been exposed to water treatment messages

in the media

Household Perceptions, Beliefs, Household Perceptions, Beliefs, and Practices Regarding Safe and Practices Regarding Safe

Water in PakistanWater in Pakistan

Dr. Mubina AgboatwallaMaria Elena Figueroa, Faisal Sarwari,

Asif Ahmed, Zahinda Khanum, Badru Nisa

Coming Soon!

HOPE: Health Oriented Preventative Education with the Safe Water Council of Pakistan

1. Water that looks clear is good for drinking (reversed)

2. It is necessary to treat water even when it comes from the tap.

3. I am responsible for the quality of my family’s drinking water.

4. Without pure water children will get diarrhea and will not be able to keep the food they eat

Items:

VarimaxFactor Loadings

- 0.81

0.84

0.76

0.45

Nine positive attitudes related to water treatmentNine positive attitudes related to water treatmentPakistan, 2005Pakistan, 2005

Nine positive attitudes related to water treatmentNine positive attitudes related to water treatment

5. I do not have time to treat drinking waterat home. (reversed)

6. I only trust water that I have treated myself.7. If children drink untreated water elsewhere

there is no reason to treat water at home.8. I would not drink water from my usual water

source without treating it myself.9. No matter how hard I try I can not get my

family’s drinking water as pure as I would like it to be.

Items:

Varimax Factor Loadings

- 0.80

0.620.85

0.72

0.63

Pakistan:N = 60 Women; k = 9 Cronbach alpha = 0.89

Five negative attitudes related to water treatmentFive negative attitudes related to water treatment

1. I don’t treat drinking water because my children don’t like treated water.

2. I treat water when it looks dirty.3. I treat water only when children get sick.4. Good health comes from God and not

from what people do to stay healthy.

5. No matter how careful a mother is, children may still get sick from diarrhea.

Items:VarimaxFactor Loadings

0.51

0.62

0.73

0.76

0.60

Pakistan: N = 60 Women; k = 5 Cronbach alpha = 0.64

Distribution of the Distribution of the meanmean positive attitude towards positive attitude towards water treatment in Pakistanwater treatment in Pakistan

Five Levels of Attitude (by scale-point)

30

17 1713

23

0

10

20

30

40

50

1 2 3 4 5

Percent

K=9 items; N = 60

Percent of women who treat their water by mean Percent of women who treat their water by mean attitude toward water treatmentattitude toward water treatment

Five Levels of Attitude (by scale-point)

0

80

100100

00

20

40

60

80

100

1 2 3 4 5

Percent

Threshold Effect?

Corr. = 0.86 (vs. -0.24)N = 60

ConclusionsConclusions• Positive attitudes are better predictors of

water treatment than negative attitudes• Hence, water treatment strategies should

be based on positive attitudes. • Preferred attributes of water should be

used to promote water treatment.• Water treatment should be promoted as

part of a cluster of health and hygienebehavior.

• Emphasize “staying healthy” rather than preventing disease, unless there is a severethreat.

Promotion Strategy for PakistanPromotion Strategy for Pakistan

Safe water promoted with positive attitudes•• Healthy and well Healthy and well

nourished childrennourished children•• Take responsibilityTake responsibility•• You can trust water you You can trust water you

have treated yourselfhave treated yourself• You can find the time to

treat your family’s water

Another approach for Pakistan: Another approach for Pakistan: Perceived image of waterPerceived image of water

Safe water promoted with preferred attributes:

•• Sweet tastingSweet tasting•• Shiny and clearShiny and clear

•• Safe Safe •• AffordableAffordable•• Easy to useEasy to use

Immediate and Delayed Feedback for Sustainable Water Treatment

Water treatment trial

Perceived Cost-effect. and social reinforcement

. . . Habit formation

Taste, smell, ease of use

Realized & perceived benefits; attitude change

Science

MM & CM Policy and Medical Community

Xpromote & reinforceif credible

time

Measurement of the Attributes of Water Measurement of the Attributes of Water in Pakistan, 2005in Pakistan, 2005

Attributes of Water 1. How shiny and clear is . . . . . . ?2. How safe for your health is . . .?3. How affordable is . . . . . . . . . . ?4. How sweet tasting is . . . . . . . .?5. How easy to use is . . . . . . . . . ?6. How important to you is

each of these qualities?

Scale Types of Water 1-5

a. Well (bored) Water . . . . . . . . . . . . . ______b. Tap Water . . . . . . . . . . . . . . . . . . . . ______c. Boiled Water . . . . . . . . . . . . . . . . . . ______d. DETTOL (Chlorine) Water . . . . . . . ______e. PuR Water . . . . . . . . . . . . . . . . . . . ______

Measurement of the Attributes of Water Measurement of the Attributes of Water in Guatemala, 2003in Guatemala, 2003

Attributes of Water 1. How clear is . . . . . . . . . . . . . . ?2. How safe for your health is . . .?3. How natural is . . . . . . . . . . . . ?4. How tasty is . . . . . . . . . . . . . . .?5. How easy to use is . . . . . . . . . ?6. How important to you is

each of these qualities? Scale

Types of Water 1-5a. Well Water . . . . . . . . . . . . . . . ______b. Tap Water . . . . . . . . . . . . . . . . ______c. Boiled Water . . . . . . . . . . . . . ______d. Chlorinated Water . . . . . . . . . . ______e. Bottled water . . . . . . . . . . . . . . ______ f. Spring water . . . . . . . . . . . . . . ______g. PuR Water . . . . . . . . . . . . . . . . ______

Image of Seven Types of Water by Five AttributesGuatemala, 2003

Table of original mean judgments of each type of waterScale: 0 to 4 (nothing to very much)

Perceived Water AttributesWater good Type clear taste safe easy natural Preferencewells 2.49 2.36 2.08 2.18 2.8 1.19tap 2.72 2.56 2.24 2.73 2.65 2.21 Meanboiled 2.58 2.44 3.20 2.61 2.67 2.92 rankchlorine2.49 1.60 2.52 2.62 2.05 0.63 of 6bottled 3.18 2.94 2.88 2.14 2.4 1.21 watersspring 2.87 2.77 2.43 2.07 3.08 0.86 Pur 2.74 2.31 2.6 2.5 2.3 2.23 Mean rating 0-4Impor-tance 2.61 1.80 2.37 1.32 1.91 --- [4-point scale]

Mean rank of 5 attributes

EasyPiped

ClearBoiled

Trust

Taste

Spring

Bottle

Chlorine

Wells

Natural

PUR

Determinants of the Rate of Adoption Determinants of the Rate of Adoption of New Technologyof New Technology

1. Attributes of the Innovation• Relative advantage• Compatibility • Complexity • Trialability (Divisibility)• Observability (Comm.) RATE OF

ADOPTION OVER TIME2. Locus of Decision (Adopter)

3. Nature of Social System

4. Communication Channels

5. Change Agent PromotionSource: Rogers (1995; 1962)

Three Criticisms Three Criticisms of Diffusion Research *of Diffusion Research *

• Pro-Innovation Bias Source of funding and personal involvement Prominence of successful innovations in research

• Individual Blame Adopter’s faultAccepting the sponsor’s definition of the “problem”System variables not amenable to changeIndividuals are the unit of observation and analysisLack of alternative causal models of change

• Social Equity * Based on 50 years of diffusion research (Rogers, 1995)

Pakistan: Pakistan: Measuring water attitudes, Measuring water attitudes, image, and treatmentimage, and treatment

Exploratory Survey:

• Household survey in February, 2005• Sindh Province • 60 households and female respondents• Self-reported answers and observation

* boiled water, chlorine solution, filter* household hygiene

HOPE: Health Oriented Preventative Education

Water treatment behavior in Pakistan, 2004Water treatment behavior in Pakistan, 2004

Treatment Method

23.38.3 10

1.7

56.7

0

20

40

60

80

100

Nottreating

Boiling Cloth Filter PUR Alum

Percentage

Sample size = 60